Elastography in Focal Scrotal Lesions: EFSUMB 2026

The Role of Elastography in Scrotal MPUS

The new EFSUMB 2026 guidelines on multiparametric scrotal ultrasound consider elastography as part of a comprehensive assessment, alongside grayscale ultrasound, Doppler methods, and contrast-enhanced ultrasound (CEUS). The practical significance of the method is to add information about the mechanical properties of tissue, primarily stiffness, when diagnostic doubts remain based on B-mode and vascular patterns.

The main limitation: stiffness does not equate to malignancy. Tumors, fibrosis, scar changes, organizing hematomas, infarcts, or inflammatory infiltrates can present a similar pattern of increased stiffness. Therefore, EFSUMB does not propose using elastography as an isolated test for decisions on orchiectomy, organ-preserving tactics, or observation.

Technologies: Strain and Shear Wave

Two groups of techniques are used in clinical practice. Strain elastography assesses tissue deformation under compression and provides predominantly qualitative or semi-quantitative information. Shear wave elastography measures the propagation of shear waves and can provide numerical values of stiffness in kPa or speed in m/s, but in the scrotum, these figures depend on technique, equipment, probe position, depth of ROI, and compression.

For the testis, minimal probe pressure, stable organ position, and comparison with surrounding parenchyma are particularly important. Excessive compression easily alters the stiffness map and can mimic pathology. The study protocol should preserve both the grayscale image of the lesion and the elastographic map with the region of interest.

What is Clinically Significant

Elastography is useful not because it provides a universal cut-off, but because it changes the probability of diagnosis in the specific context of MPUS. A lesion that appears solid on B-mode, has internal vascularization, and significantly differs in stiffness from surrounding parenchyma requires more cautious interpretation. Conversely, the absence of convincing stiffness increase does not rule out a tumor and should not negate the assessment of vascularity, contrast enhancement, and clinical data.

For conclusions, the formula "stiff — malignant" is less important than the consistency of signs: echostructure, contours, localization, Doppler signal, presence or absence of contrast enhancement, dynamics, and laboratory-clinical background.

Testicular Focal Lesion

In intratesticular focal lesions, elastography can increase confidence in tissue characterization. It is especially useful when the lesion is small, non-palpable, or has ambiguous signs on B-mode. Increased stiffness may support suspicion of a solid lesion but does not replace the oncological algorithm.

The ultrasound physician should describe the lesion's location, size on grayscale ultrasound, echogenicity, contours, relation to the tunica albuginea, vascularization, and elastographic pattern relative to normal parenchyma. If shear wave elastography is performed, numerical values can be indicated only as equipment-dependent parameters, without reference to a universal norm for cancer exclusion.

Scrotal Incidentaloma

Incidental lesions are more often detected during ultrasound for pain, infertility, varicocele, or nonspecific discomfort. In this situation, MPUS helps differentiate clearly cystic, vascular, post-traumatic, inflammatory, and suspicious solid findings. Elastography adds one layer of information: a soft, homogeneous, and avascular lesion combined with a typical B-mode picture is interpreted differently than a stiff solid lesion with internal blood flow.

EFSUMB emphasizes that management should not be based solely on the elastogram. For incidentalomas, it is especially important to correlate with history, tumor markers, physical examination data, and the possibility of dynamic monitoring or organ-preserving approach based on clinical indications.

Scrotal Trauma

In trauma, B-mode, Doppler perfusion assessment, and, if necessary, contrast-enhanced ultrasound are primary. Elastography can be additional for assessing altered parenchyma, hematoma, or the area of injury organization, but in the acute period, its informativeness is limited by pain, swelling, and inability to standardize compression.

Stiff areas post-trauma should not be automatically interpreted as tumors. Important are the topography of the injury, relation to hematoma, condition of the tunica albuginea, perfusion of viable parenchyma, and dynamics. If signs do not align with a traumatic scenario, the lesion should be evaluated according to the intratesticular lesion algorithm.

Infertility and Diffuse Changes

In the infertility section, elastography is considered as a method for additional characterization of testicular parenchyma. It can record diffuse changes in the mechanical properties of tissue but is not a substitute for clinical, hormonal, and andrological assessment. Individual stiffness values should not be interpreted as an independent marker of spermatogenesis.

In infertility, it is more useful to standardize the protocol: same patient position, same side scanning, minimal probe pressure, several stable measurements with SWE, documentation of comparison between the right and left testis. The conclusion should be descriptive and integrated with testicular volume, echostructure, signs of varicocele, and vascular data.

Oxford Scale in the EFSUMB Document

The EFSUMB guidelines use the Oxford system to denote the level of evidence and strength of recommendations. This is important for practice: the lower the evidence base, the more cautiously elastographic signs should be translated into clinical decisions. For scrotal elastography, many conclusions require integration with other MPUS modes and clinical context.

How to Write a Conclusion

The optimal formulation should be descriptive. It should indicate the type of elastography, quality of the study, comparison with surrounding parenchyma, homogeneity or heterogeneity of stiffness, presence of compression artifacts. For SWE, measured values can be provided, but without a categorical conclusion based on a single number.

The recommended logic of the conclusion: first anatomy and B-mode, then vascularity, then elastographic pattern, then integral assessment in the context of MPUS. If signs are contradictory, this should be directly reflected: for example, "elastographic data are nonspecific; correlation with Doppler, contrast, and clinical-laboratory data is necessary."

Key Limitations

• No single stiffness threshold for differentiating benign and malignant testicular lesions.
• Results depend on equipment, probe, ROI, compression, and operator experience.
• Fibrosis, hematoma, infarct, and inflammation can be stiff and mimic tumor patterns.
• A soft pattern does not exclude a tumor with suspicious B-mode or Doppler signs.
• Elastography is most valuable as part of MPUS, not as a standalone screening test.